Nursing Elites

1. A nurse is assessing a client who has a urinary tract infection and is receiving ciprofloxacin. Which of the following findings should the nurse report to the provider?

• A. Dry mouth.
• B. Photosensitivity.
• C. Headache.
• D. Urinary retention.

Correct answer: B

Rationale: The correct answer is B: Photosensitivity. Ciprofloxacin can cause photosensitivity, making the client more sensitive to sunlight. It is essential for the nurse to report this finding to the provider so that appropriate measures can be taken to prevent skin damage. Dry mouth, headache, and urinary retention are not typically associated with ciprofloxacin use and do not require immediate reporting to the provider in this scenario.

2. A nurse is providing discharge teaching to a client who has had a stroke. Which of the following instructions should the nurse include?

• A. Avoid taking anticoagulant medication.
• B. Limit fluid intake to 1,000 mL per day.
• C. Avoid isometric exercises during recovery.
• D. Perform range-of-motion exercises daily.

Correct answer: D

Rationale: The correct answer is D: Perform range-of-motion exercises daily. After a stroke, performing range-of-motion exercises can help prevent complications such as joint stiffness and contractures. Options A, B, and C are incorrect. Anticoagulant medications are often prescribed to prevent blood clots after a stroke, fluid intake should be adequate unless indicated otherwise, and isometric exercises can be beneficial during recovery.

3. A nurse is providing discharge teaching to a client who is postoperative following a mastectomy. Which of the following instructions should the nurse include?

• A. Avoid using deodorant until the incision heals.
• B. Perform arm exercises 24 hours after surgery.
• C. Wear tight-fitting clothing to support the incision.
• D. Perform arm exercises 2 days after surgery.

Correct answer: A

Rationale: The correct instruction for the nurse to include is to advise the client to avoid using deodorant until the incision heals. Using deodorant can lead to skin irritation, which should be prevented following a mastectomy. Choice B is incorrect because performing arm exercises should typically be delayed until recommended by the healthcare provider to prevent strain on the surgical site. Choice C is incorrect as tight-fitting clothing can increase discomfort and hinder proper healing. Choice D is also incorrect because initiating arm exercises should be based on the healthcare provider's guidance and not a specific timeframe.

4. A healthcare provider is caring for a client who has a new prescription for enoxaparin. Which of the following actions should the healthcare provider take?

• A. Administer the medication intramuscularly.
• B. Inject the medication into the client's abdomen.
• C. Massage the injection site after administration.
• D. Aspirate for blood return before administering.

Correct answer: B

Rationale: The correct answer is to inject the medication into the client's abdomen. Enoxaparin is a medication that should be administered subcutaneously into the abdomen to ensure proper absorption. Choice A is incorrect because enoxaparin should not be administered intramuscularly. Choice C is incorrect because massaging the injection site after administration is not recommended for enoxaparin injections. Choice D is incorrect because aspirating for blood return is not necessary before administering a subcutaneous injection like enoxaparin.

5. A client with heart failure is prescribed furosemide. What finding should the nurse report to the provider?

• A. Sodium 140 mEq/L
• B. Heart rate of 82/min
• C. Potassium level of 2.8 mEq/L
• D. Oxygen saturation 95%

Correct answer: C

Rationale: The correct answer is C. A potassium level of 2.8 mEq/L is low and should be reported to the provider. Furosemide can cause potassium depletion, leading to hypokalemia. Low potassium levels can result in cardiac dysrhythmias, which is a serious concern in clients with heart failure. Choices A, B, and D are within normal ranges and do not require immediate reporting. Sodium level of 140 mEq/L, heart rate of 82/min, and oxygen saturation of 95% are all acceptable findings.

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